1-800-877-6660

2500 Apalachee Pkwy.

Tallahassee, FL 32301

850-877-6660

Contact Us

Request for Health Insurance Quote

Life Insurance Information
Type	Primary Secondary
Amount of Death Benefit	100,000 200,000 300,000 400,000 500,000 600,000 700,000 800,000 900,000 1,000,000 1,000,000+
Insured Information
First Name:
Last Name:
Telephone Number:
Email Address:
Address:
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Postal Code:
Date of Birth
Use Tobacco	Yes No
Gender	Male Female
Height
Weight
Insured Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Spouse Insurance Information
Spouse to be Insured?	Yes No
Spouse Date of Birth
Spouse Use Tobacco?	Yes No
Gender	Male Female
Height
Weight
Children	Yes No
Spouse Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Children Information
Date of Birth Gender Child 1 Male Female Child 2 Male Female Child 3 Male Female
Children Medical Information
Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage
Disability Insurance Information
Occupation
Duties
Earnings
Earnings Frequency	Weekly Monthly Yearly
Other Disability Coverage?	Yes No
Other Disability Coverage Type	Individual Group
Disability Benefits to be Quoted
Elimination Period STD	180 Days 90 Days 60 Days 30 Days
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD	Age 65 5 Years 2 Years
Elimination Period LTD	180 Days 90 Days 60 Days 30 Days
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD	Age 65 5 Years 2 Years
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

2500 Apalachee Parkway, Tallahassee FL 32301

(Directly Across From Circuit City)

850-877-6660 / 1-800-877-6180

Hours of Operation: Monday - Friday 8:30am-5:30pm, Saturday 10am-2pm,

Closed Sunday.